GASTRO-INTESTINAL BLEEDING

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• Introduction • Site of Bleeding • History • Physical Examination • Laboratory Tests • Investigation • Treatment • References

Introduction

Gastrointestinal bleeding is an uncommon but important sign in paediatric patients.

Patients with acute significant blood loss will need urgent IV access & resuscitation. Refer to guidelines for CPR &/or Shock

Tachycardia is an important sign of hypovolaemia in paediatric patients with blood loss

There are many causes of GI bleeding in children.

Important factors that help determine aetiology and focus interventions include: Site of bleeding

Age of onset

Presence of abdominal pain Presence of diarrhoea

NB: For patients with liver disease see separate guideline – GI bleeding in Liver Disease

Site of bleeding

Non GI mimics of GI blood loss.

• Epistaxis, maternal blood, dental work, haemoptysis. Substances such as iron, bismuth, beets, spinach and blueberries can mimic melaena

Upper GI (mouth to the ligament of Treitz, the 2nd part of the duodenum) • Haematemesis (vomited blood)

o Bright red suggests active bleeding

o Altered blood – may be black (resembling coffee ground) suggests less active bleeding

• Upper GI blood loss may present as melaena (see table next page)

Lower GI (distal to the ligament of Treitz)

• Melaena (black, tarry odiferous stool) suggests blood proximal to ileocaecal valve

• Haematochezia (bright red blood per rectum) generally indicates a colonic site of bleeding. Occasionally red blood in the stool may originate from the small intestine as a result of rapid gut transit.

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Haematemesis

Oesophagus Mallory–Weiss tear

Oesophageal varices Oesophagitis

Repeated vomiting

Stigmata of chronic liver disease or portal hypertension Reflux symptoms

Stomach H. pylori peptic ulcer

Non-helicobacter

gastritis Non steroidal anti-inflammatory use

Small intestine H. pylori/peptic ulcer

Haemolytic uraemic syndrome Henoch–Schoenlein purpura Arteriovenous malformation Crohn’s disease Haemangioma Intestinal necrosis Elevated urea Rash

Cutaneous A-V malformations Weight loss, diarrhoea Cutaneous haemangiomata

Rectal Blood Loss

Painless Painful

< 3 months 3-24 months > 2 years < 3 months 3-24 months > 2 years

Swallowed maternal blood Vit K deficiency Gastritis Vascular malformation Haemophilia Mallory-Weiss tears Allergic colitis Meckel’s diverticulum Vascular malformation Polyps Malformation Polyps Mallory-Weiss tears Meckel’s diverticulum Oesophageal varices Necrotising enterocolitis Anal fissure Oesophagitis Gastritis

Peptic Ulcer disease Intussusception Infectious colitis Inflammatory bowel disease Peptic ulcer Anal fissure Infectious colitis Peptic ulcer disease Oesophagitis Inflammatory bowel disease Henoch-Schonlein purpura Intussusception

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History

• Constipation (possible anal fissure)

• Diarrhoea (inflammatory bowel disease/ infectious causes Salmonella, Campylobacter, Shigella, entero-invasive E.coli and Yersinia)

• Recent antibiotic exposure (clostridium difficile)

• Liver disease (oesophageal varices and vitamin K deficiency) • Bleeding disorders

• Cystic fibrosis (oesophageal varices and vitamin K deficiency)

• Medication exposure NSAIDs (gastritis) and prior antibiotic exposure (pseudomembranous colitis)

• Overseas travel (infectious)

• Family medical history (peptic ulcer disease, bleeding disorders, inflammatory bowel disease, polyposis syndrome. Other sick contacts may indicate an infectious cause)

Phys

Physical Examination

ical Examination

Look for:

• Tachycardia

• Hypotension is a late and ominous sign in GI bleeding

• Orthostatic hypotension (a rise in the pulse rate by 20 beats per minute or a fall in the systolic blood pressure of more than 10mmHg indicates significant volume depletion, usually > 20%).

• Abdominal tenderness suggesting a surgical cause of pain, haemolytic uraemic syndrome, gastric/ duodenal ulceration

• Anal fissure - constipation

• Anal skin tags suggesting Crohn’s disease.

• “Haemorrhoids” are an uncommon in paediatric and adolescent patients. Anal skin tags are a common mimic of “haemorrhoids”. Presence of true anal varicosities suggest portal hypertension.

• Stigmata of liver disease (hepatosplenomegaly, jaundice, cutaneous purpura, spider naevi, clubbing, ascites)

• Cutaneous haemangiomata may indicate the presence of GI mucosal haemangiomata. • Pigmentation of the lips and buccal mucosa may suggest Peutz-Jeghers syndrome. • Purpura on the buttocks and lower extremities are characteristic of HSP.

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Laboratory Tests

• FBC - A recent bleed may not initially alter the haemoglobin or haematocrit. The MCV can be low in chronic low grade bleeding. Raised eosinophils may signify an allergic colitis. • ESR/ CRP - may indicate inflammatory bowel disease or sepsis

• Coagulation profile to rule out a liver disease, bleeding disorder or disseminated intravascular coagulopathy.

• Liver function tests if there are signs of portal hypertension or chronic liver disease. • Stool cultures and a C-difficile toxin assay if there are loose stools.

• Renal function tests. A high urea may be a clue for haemolytic uraemic syndrome or may indicate the presence of dehydration. A high urea may also be due to resorbed blood in the upper GI tract

• H.pylori stool antigen is not recommended as H.pylori has a very high prevalence in the general paediatric population. H.pylori is diagnosed via endoscopy.

Investigation

Fibreoptic endoscopy and biopsy has increased the rate of positive diagnosis. The yield decreases if endoscopy is delayed, so it is important that endoscopy occurs promptly. Preparation of the patient is critically important. In emergency situations where bleeding is severe, resuscitation of the patient is paramount. Endoscopy should not be performed hastily if the patient is unstable.

Upper GI bleeding

Significant upper GI bleeding requires endoscopy for investigation. Contrast studies should not be the initial study to rule out oesophagitis, gastritis or peptic ulcers because of the lack of sensitivity. Contrast studies may be indicated in patients with dysphagia or odynophagia. Ultrasound should be requested if there is evidence of liver disease or splenomegaly.

Haemotochezia

Colonoscopy is the best test for significant lower GI bleeding. An exception is suspected

intussusception, where ultrasound should be requested (and if confirmed, an enema for reduction). Massive painless rectal bleeding

A Meckel scan is the procedure of choice. CT angiography may also help localize bleeding for AV malformations

Obscure bleeding in the GI tract

Capsule endoscopy may provide a diagnosis in some cases.

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Treatment

1. If there is significant bleeding: 2X large bore IV lines

re-establish blood volume (rapid infusion of 0.9% NaCl +- by red cells).

2. Acid suppression Omeprazole (2mg/kg/day). Patients < 7 years should receive q12hourly dosing.

3. Urgent referral to appropriate teams PICU/ Surgery/ General Paediatrics/ Gastroenterology 4. Significant GI bleeding requires admission for observation +- ongoing investigation and treatment.

5. Never discharge a patient with liver disease and GI bleeding unless discussed with on-call Paediatric Gastroenterologist/Hepatologist (separate guideline for GI bleeding in liver Disease).

References

emedicine Paediatics. Gastrointestinal Bleeding. R Y Hsia, J Halpern, O L de Mola updated Dec 8, 2009

Vinton N. Gastro-intestinal bleeding in infancy and childhood, Gastroenterol Clin North Am 1994; 23: 93-122.

Ament M. Diagnosis and management of upper gastro-intestinal bleeding in the paediatric patient. Pediatr Rev 1990; 12: 107-116.

Siafakas C, Fox V, Nurko S. Use of Octreotide for the treatment of severe gastro-intestinal bleeding in children. J Pediatr Gastroenterol Nutr 1998; 26: 356-359.

Treem W. Gastro-intestinal bleeding in children. Gastrointest Endosc Clin North Am 1994; 4: 75-97.